Knowledge of Lassa fever and use of infection prevention and control facilities among health care workers during Lassa fever outbreak in Ondo State, Nigeria

Introduction Hospital-acquired infections of Lassa fever (LF) have been described in many West African countries. We assessed the availability of Infection Prevention and Control (IPC) measures and their use in the health centres (HCs) at the affected Local Government Areas (LGAs) during an ongoing LF outbreak in Ondo State, Nigeria. Methods We included all primary and secondary HCs and their healthcare workers (HCWs) in the affected Ose and Owo LGAs. We collected data from respondents using self-administered questionnaires and used a checklist to assess the IPC measures at the HCs. We generated frequencies and proportions and tested associations using odds ratios at 95% CI. Results One hundred and ninety HCWs from 59 HCs were surveyed of which 34 (57.6%) were located in Owo LGA. All HCs had soap for handwashing, 57(96.6%) had wash-hand basins but only 52(88.1%) had water. While 57(96.6%) had gloves and 53(89.8%) had sharps boxes, only 16(27.1%) had an isolation room. Only 44(23.2%) respondents had been trained in IPC. The majority, 144 (91.6%) always had gloves available for their use, 79(41.6%) always had facemask/shield and 71(37.4%) always had full personal protective equipment. At the last patient contact, only 151 (79.8%) washed their hands before the contact, 188(98.9%) washed their hands after and 183 (96.2%) wore gloves. While there was no association between availability of gloves and its use (OR: 0.21, 95%CI 0.04-1.17), there was significant association between having had training in basic universal precautions and having used gloves (OR: 3.64, 95%CI 1.21-19.40) and having washed hands after last patient contact (OR: 2.31, 95%CI 1.67-12.30). Conclusion Among these HCs that serve as point of first contact with possible cases of LF in these endemic LGAs, none met the minimum standard for IPC. We recommend that IPC committee for each LGA and the whole state should be set up and IPC trainings made mandatory.


Introduction
Lassa fever is a zoonotic disease caused by an arenavirus, the lassa virus, so named after the town in Nigeria where it was first isolated [1]. Humans contract the virus primarily through contact with the contaminated excreta of Mastomys natalensis rodents (commonly known as the Multimammate rat), which is the natural reservoir for the virus. The infected rodents are reservoirs capable of excreting the virus through urine, saliva, excreta and other body fluids to man [2]. Secondary transmission of the virus between humans occurs through direct contact with infected blood or bodily secretions. This occurs mainly between individuals caring for sick patients although anyone who comes into close contact with a person carrying the virus is at risk of infection. Incubation period of Lassa fever is 1-3 weeks. It presents with symptoms and signs indistinguishable from those of febrile illnesses such as malaria and other viral haemorrhagic fevers such as Ebola. In approximately 80%, symptoms are mild and are often undiagnosed. Death may occur within two weeks after symptom onset due to multi-organ failure [3]. While approximately 15%-20% of patients hospitalized for Lassa fever die from the illness, only 1% of all lassa virus infections result in death [4].
Nosocomial transmission of Lassa fever in healthcare facilities represent a significant burden on the healthcare system [5].
Infection prevention and control (IPC) in healthcare settings has been documented as an important factor in controlling potential outbreaks of Lassa fever [6]. In support of this, studies have shown that in hospitals with improved IPC practices, transmission of Lassa virus was minimal [7,8]. Lassa fever is endemic in parts of West Africa including Sierra Leone, Liberia and Nigeria; affecting about 100,000 to 300,000 people every year in this regions [9,10] [12].

Study population:
We carried out the study among HCWs who had been working in either secondary or primary health centers in the selected LGAs for at least six months prior to the commencement of our study.

Sampling:
We did a total sampling of all primary and secondary health centers (both government and private owned) and their HCWs in the selected LGAs.   were registered nurses, 24 (12.6%) were auxiliary nurses or auxiliary trainee nurses and 1 (0.5%) was a doctor (Table 1).
Among the respondents, only 44 (23.2%) have had a training in infection prevention and control (IPC).

Overall knowledge
The overall knowledge score achieved by all respondents was 24

Knowledge of epidemiology of Lassa fever
The mean score on knowledge of epidemiology of Lassa fever among all respondents was 6.8 (±1.5). There was a statistically significant difference between the mean score among respondents from government owned facilities (mean score = 6.9 ±1.3) and private (mean score = 6.2 ±2.2) (p = 0.015). Only 26.8% had good knowledge and there was no statistically significant relationship with profession (p=0.325), facility ownership (p = 0.474) and LGA (p=0.413) ( Figure 1).

Knowledge of clinical features
The mean score achieved by all respondents was 11.4±2.4. There was a statistically significant difference between the mean score among respondents in government facilities (11.6±2.1) and private  (Figure 3) Mean knowledge score achieved by all respondents was 6.2 ±1.6.

Knowledge of precautionary measures
There was a significant association between mean knowledge scores of respondents from government facilities (mean score=6.4±1.4) and those from private (mean score= 5.5±1.6), (p=0.03).

Availability of Personal Protective Equipment (PPEs) at work place
In all, 174 (91.6%), always had gloves available for their use, 79

Discussion
General knowledge of Lassa fever was low among health workers in the Lassa fever endemic LGAs under study. Particularly, the knowledge of the clinical features of the disease was low despite the fact that early diagnosis and treatment with ribavirin contributes significantly to survival from Lassa fever [9]. This could mean that even if patients with Lassa fever present early at health facilities, The difference in the results however, maybe due to the fact that doctors and nurses constituted the majority of their respondents and the studies were conducted at tertiary health facilities that were specialised in caring for Lassa fever cases [13,14]. However, the study by Aigbiremolen which was conducted among staff of primary health facilities only and used 75% as a cut off, found that almost 80% of the respondents had good knowledge [15]. The same study found that Community Health Extension Workers (CHEWs) had poorer knowledge of Lassa fever than trained nurses as this study did [15]. Therefore, the low knowledge found in this study could also be due to the high proportion of CHEWs and trainee auxiliary nurses [16]. However, other studies have also documented poor knowledge among other cadres of health workers (16).
A similarly low knowledge was found by the study of Ekuma and Akpan which was conducted in a tertiary facility among medical students, interns and resident doctors in Uyo [17]. Therefore, it is also possible that other factors apart from profession and level of healthcare practice influence the acquisition of knowledge on Lassa fever. In addition, while a study by Olowookere et al found an association between ownership of health facility and knowledge of Lassa fever [18], we did not find a significant relationship. The study by Aigbiremolen did find that workers at private HCs had better knowledge than the workers at government owned PHCs though this relationship was also not significant [15]. Knowledge of precautionary measures was on the average and comparable with that of the findings of Izegbu et al in Lagos although there's was conducted among laboratory staff only [19]. While the use of PPE was also comparable with that of the findings of Adebayo et al [14].
According to Adewuyi et al, the most dangerous exposure is parenteral and must be avoided through staff training [20].
Unfortunately, the result of the study shows that less than a quarter of the healthcare workers in these LGAs that are endemic for Lassa fever have had any training on IPC. Training of health workers on priority diseases is of importance [21]. The recommendation is for such patients to be treated in isolation rooms with adequate PPEs available at all times [22], our study found that none of the secondary health facilities had neither an isolation room nor have PPEs routinely available.
Concerning the routine practice of IPC measures, different studies have found varying levels of IPC practice in different parts of the country similar to what was found by this study [15,[23][24][25][26][27]. The consistent finding in all the study is that the practice of IPC was poor irrespective of the level of health facility. While it was not the focus of this study, it was however found that there was a lack of Page number not for citation purposes 5 qualified health personnel at the primary and secondary health facilities that were studied. Community Health Workers (CHEWs) constituted majority of the workforce in the facilities. There was also a high proportion of auxiliary nurses/trainees. However in Nigeria, CHEWs are expected to predominantly be at the primary health care level [28,29], this is not supposed to be so at secondary health care level. This pattern seen here is probably because there is lack of incentives for qualified personnel to work at primary and secondary healthcare facilities especially those located in semi-rural or rural places. This further proves that we still have a mal-distribution of healthcare workers in the country [30]. A major limitation of this study was a probable high proportion of acceptable IPC practices among the respondents than usual as these were self-reported and thus prone to bias.

Conclusion
This study found that the knowledge of HCWs about Lassa fever, its

Competing interests
The authors declare no competing interests.

Authors' contributions
ITI, OSI, OA, IO and AA developed the concept note and participated in data collection. ITI and OSI analysed the data using the data analysis plan accepted by all authors. Draft manuscript was written by ITI. All authors read and approved the final manuscript.